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\begin{document}

\title{Scar Endometriosis After Cesarean Section: A Rare Report of Cyclic Pain
and Bleeding}



\author[1]{Sudip Yadav}%
\author[2]{Manish Yadav}%
\author[2]{Bishal Gupta}%
\author[3]{Newton Shah}%
\author[1]{Aishwarya Gupta}%
\author[4]{Dikshya Khanal}%
\author[5]{Rahila Lamichhane}%
\author[5]{Avinash Yadav}%
\author[6]{Nikita Shah}%
\author[2]{Digraj Yadav}%
\affil[1]{Universal College of Medical Sciences and Teaching Hospital}%
\affil[2]{Tribhuvan University Institute of Medicine}%
\affil[3]{Tribhuvan University Teaching Hospital}%
\affil[4]{KIST Medical College}%
\affil[5]{Nepal Medical College Teaching Hospital}%
\affil[6]{Kathmandu Medical College and Teaching Hospital}%


\vspace{-1em}



  
  \date{March 17, 2025}


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\section*{Case History/Examination:}

{\label{case-historyexamination}}

A 27-year-old woman presented with a history of pain and pinpoint
cyclical bleeding at her cesarean scar during menstruation for 2 years.
The dull ache worsened during menstruation. Her menstrual cycle was
regular, occurring every 30 \selectlanguage{ngerman}± 2 days, with a flow of 5-6 days and
associated dysmenorrhea, but no clots. Her last menstrual period was on
January 6, 2024. Clinical examination showed normal vital signs.
Per-abdominal examination revealed a non-mobile, hyperpigmented mass
approximately 3×2 cm in size protruding from the left corner of the
Pfannenstiel incision scar, tender upon palpation. A 5-cm indurated area
surrounding the scar appeared healthy with no lumps. Methods:
Differential diagnoses included surgical scar endometriosis, abscess,
and complicated surgical scar hernia.The patient's medical history
included two cesarean sections via a Pfannenstiel incision. The first
was performed 6 years ago due to cephalopelvic disproportion, and the
second was done 2 years ago. Both pregnancies were uneventful, but she
developed a surgical site infection (SSI) after the second procedure and
received outpatient treatment at our center due to her refusal of
hospital admission. Three months after her second delivery, she began
experiencing bleeding from her cesarean scar site during menstruation,
along with lower abdominal and back pain. An ultrasonography (USG) of
the abdomen and pelvis was performed, showing an irregular heterogeneous
lesion measuring approximately 0.8 cm × 0.71 cm with predominantly
hypoechoic echotexture and scattered hyperechoic echoes internally,
located within the previous LSCS scar, suggestive of scar endometriosis.
With a provisional diagnosis of scar endometriosis, she was prescribed
medical management with Paracetamol 500 mg and Norethisterone 5 mg for
2.5 months. The patient then underwent surgical excision of the scar
endometriosis under spinal anesthesia. An elliptical incision was made
around the scar tissue, and the endometrial tissue was excised with
clear margins. On gross examination, the specimen consisted of a single
piece of skin and hair-attached tissue, light brown to dark brown in
color, firm in consistency, and measuring 3.5 × 1.8 cm. A specimen of
subcutaneous tissue was sent for histopathological examination, which
revealed endometrial glands lined by columnar cells within the dermis,
surrounded by stroma(Fig 1). The adjacent area showed variable-sized
blood vessels with hemorrhages and mixed inflammatory cells(Fig 2). No
cellular atypia or granulomas were observed. The patient's follow-up was
uneventful. She reported significant improvement in symptoms with no
recurrence of pain or bleeding at the scar site.

\section*{Conclusion and Results}

{\label{conclusion-and-results}}

The surgical wound healed well without any signs of infection or
complications.



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      1 Conclusion 
      In conclusion, scar endometriosis poses a challenge in diagnosis, often
causing frustration for both patients and physicians alike. It is
imperative for healthcare providers to maintain a vigilant approach,
particularly when encountering women experiencing pain at incision sites
post pelvic surgery. A comprehensive evaluation, including a detailed
medical history and physical examination, is crucial. Surgeons must
consistently include scar endometriosis in their differential diagnosis
to ensure timely recognition and appropriate management. USG and MRI
serve as valuable diagnostic aids. Opting for wide excision is preferred
as pharmaceutical interventions might not yield sustained alleviation.
    
    1 Conclusion

\section*{Author Contributions}

{\label{author-contributions}}

NAS,MY, SKY,BG,AG wrote the original manuscript, and reviewed, and
edited the original manuscript. DY, RL,DK, AY, NS reviewed and edited
the original manuscript.

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      1 Conflicts of interest
Statement
      The authors have no conflict of interest to declare.
    
    1 Conflicts of interest Statement

\section*{Funding Statement}

{\label{funding-statement}}

All authors have declared that no financial support was received from
any organization for the submitted work.

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      1 Consent
      Written informed consent was obtained from the patient for publication
of this case report and any accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of this journal
on request.
    
    1 Consent

\section*{Data Availability}

{\label{data-availability}}

All the required information is within the manuscript itself.

\section*{Provenance and peer review}

{\label{provenance-and-peer-review}}

Not commissioned, externally peer-reviewer



\section*{References:}

{\label{references}}

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